In the past week, many people have been deeply impacted by the “Open Letter to MANA” promoted by "Women-Centered Midwifery" in response to the shift to inclusive language in MANA’s Core Competencies. Some have clearly recognized the harm in the ideas represented in the letter, others have struggled to understand why it is harmful, and still others have signed on to the letter in agreement. The purpose of this response is to explain why and how the Open Letter is harmful to transgender, genderqueer and intersex people, why midwifery documents should be gender inclusive, and why people of all genders should be welcomed into midwifery care. While we are focusing on birth-related care in this letter, it is important to notice the subtle and insidious ways the "open letter" attempts to erase the lives and narratives of transgender women and other women who cannot or do not give birth. Parenting, including mothering, represents a diverse set of experiences that may or may not include giving birth.

The authors of this letter would like to preface our response to the “Open Letter to MANA” by conveying the following:

We honor and uphold the right to self-determination and bodily autonomy for all people. We believe that as midwives, our purpose is to support parents and babies throughout the childbearing year, taking into account the unique physiological, psychological, and social well-being and needs of each client. It is our work to provide individualized education and counseling, as well as client-centered prenatal, intrapartum, and postpartum care. We understand the importance of providing compassionate, holistic, and culturally sensitive midwifery care, and we strive towards making the Midwives Model of Care™ accessible for every person and family who seeks it, regardless of race, ethnicity, religion, ability, sexual orientation, gender identity or gender expression. We acknowledge the disproportionate effects of transphobia on those with other marginalized identities such as being a person of color, low-income or disabled. Many racial health disparities that concern midwives and impact our communities are experienced in greater numbers by people who are both Black and transgender. These lives especially are in need of the kind of respectful, compassionate, and individualized care midwives can offer. We assert that we can honor the power of the female body and at the same time extend this reverence to all people who are pregnant and giving birth, and that to do so is in full alignment with the heart of midwifery.

The Open Letter denies the existence of transgender and genderqueer people.

The letter refers to, “accelerating trends in our culture to deny material biological reality,” and asserts that, “We know as midwives that biological sex occurs at the level of our DNA and the gametes we produce, and is immutable.” As healthcare providers, it is not our place to decide whose self-expression is legitimate and whose is not. As midwives, our role is to understand the people we are caring for, to provide care that is sensitive to individual differences, and to take into consideration the evolving nature of our society. The fact is, transgender and genderqueer people do exist. Furthermore, as health care providers it is our obligation to keep in mind the full range of human physiology, including the existence of intersex conditions, in which a person’s DNA may not match their external sex characteristics. This naturally occurring human genetic expression is a reminder that humans are not binary beings, (not always just male or female) physiologically or otherwise.

The Open Letter asserts that the bodily possession of a uterus and the ability to give birth makes a person female, and nothing other than female.

“By embracing the idea that any human other than those in a class called women carry offspring to term, give birth to them and nurse them, we are prioritizing gender identity over biological reality.” The statement rejects the autonomy and self-determination of any person who gives birth and does not identify as female or as a woman.

The Open Letter dismisses and invalidates the self-knowledge and experience of transgender, genderqueer and intersex people.

“Pregnancy and birth are distinctly female biological acts; only women and female-bodied people can give birth.” The authors and signators purport the point of view that if a person has a uterus and gives birth, that person is inherently a woman. The Open Letter denies the existence of, validity and lived experience of an entire group of people who know themselves to be male or to be other than “woman” and give birth.

The Open Letter asserts that using language that includes people of all genders erases the inclusion of women.

“We are also contributing to the cultural erasure of women’s wisdom that the physiological power encoded in our female bodies is what creates, nourishes, and births live offspring and transmits culture.” The MANA core competency that relates to this statement does not erase the existence of women, it simply extends it to all people who give birth. The MANA core competency states, “The biological wisdom to give birth is innate, it has been held throughout time, and is experienced across cultures by all pregnant people.” Furthermore, it stands to reason that women identify as people, therefore women are not excluded by the use of the word “person” to refer to them. However, there are pregnant people who do not identify as “women” and feel excluded or misidentified by the use of the word “women” in reference to them. Therefore, use of the word “people” is inclusionary, while use of the word “women” is exclusionary.

The Open Letter conveys a lack of understanding about gender identity and gender expression, reducing the term “gender” to binary sex role stereotypes.

“Sex is natural, biological and objectively factual. Gender refers to societal roles and expectations placed upon members of each sex. Gender is cultural and gender norms vary across the globe. Gender is in fact synonymous with what not so long ago were called sex-role stereotypes.” Transgender and genderqueer people and their allies have worked to educate the world so that there is a greater understanding of the difference between sex and gender, and the nuances of gender. Below are some helpful terms to broaden understanding.

These terms apply to all people, not just transgender, genderqueer, or intersex people:

Gender: A socially constructed system of classification that ascribes qualities of masculinity and femininity to people. Gender characteristics can change over time and are different between cultures

Gender Identity: An individual’s internal sense of being male, female, or something else. Since gender identity is internal, one’s gender identity is not necessarily visible to others.

Gender Expression: How a person represents or expresses one’s gender identity to others, often through behavior, clothing, hairstyles, voice or body characteristics.

These terms apply to people whose gender identity and expression are not in full alignment with their sex:

Transgender: A term for people whose gender identity and expression are different from those typically associated with their assigned sex at birth.

Genderqueer: A term used by some individuals who identify as neither entirely male nor entirely female.

Intersex: A term used for people who are born with a reproductive or sexual anatomy and/or a chromosome pattern that does not fit typical definitions of male or female.

While the differences in the definitions of “gender” used in the Open Letter and in trans-positive communities are subtle, note that the second definition refers to “qualities of masculinity and femininity” which is different than sex role stereotypes, i.e. “That dress is so beautiful and feminine.” (a quality) versus “Women are good at cooking and cleaning.” (a sex role stereotype). Also, gender can be more fully understood by the terms “gender identity” and “gender expression.” The authors and signators of the Open Letter demonstrate a lack of understanding of the nuances of gender.

The Open Letter claims that transgender people are "unnatural."

“The whole concept that a man can give birth is premised on the supremacy of technology over women and nature, and the primacy of ideology that is detached from our animal, natural selves.” This statement claims that a pregnant person who identifies as male is somehow asserting dominance over nature and detaching themselves from the natural world. We assert that there is nothing more natural than knowing oneself.

The Open Letter denies the experience of gender identity by all people who give birth.

“We believe that it is a mistake to define the experiences of pregnancy and childbirth through the lens of gender identity…We are allowing gender identity to be the primary way that we refer to one another, even for a biological process like birth.” By claiming that birth is merely a biological process, devoid of one’s experience of their gender, the authors and signators are overlooking the fact that everyone has a gender identity, and we all experience our gender identity as an inherent part of who we are, including when giving birth. Gender identity is central to one’s lived experience, both for those who identify with the gender they were assigned at birth and for those who do not; we believe in the importance of respect for the gender identities of all people, including women.

Along with inaccurately using the word “gender,” the Open Letter also erroneously asserts that all transgender people take hormones:

“Gender, as used today, also refers to the results of consuming powerful steroid hormones to change secondary sex characteristics, and therefore the perception of one’s sex." Some transgender and genderqueer people take hormones, and others do not. Some have surgeries to alter their bodies, and some do not. Some people take hormones for a while, and then stop - including those who are seeking pregnancy or find that they have become pregnant. The decision to take hormones and to undergo a hormonal transition is very complex. It is often guided by a person’s need to feel safe in the world, physically, psychologically and emotionally. Simply put, it saves lives. Think of a transgender teen, going through a puberty that is the opposite of who they know themselves to be. Is it no wonder that nearly half of all transgender teens attempt suicide? The rate of attempted suicide remains at 45% throughout the childbearing years. In fact, a 2014 study by the Williams Institute showed that the suicide rate is highest for transgender men of childbearing age and people of color.

The Open Letter promotes a double-standard regarding the rights and privileges of women that they are not willing to extend to all people.

“Women have a right to bodily autonomy and to speak about their bodies and lives without the demand that we couch this self-expression in language which suits the agenda of others who were not born female.” We support the idea that everyone has the right to bodily autonomy and to speak about their bodies and lives in ways that suit them - this right does not only extend to women. As an international organization, MANA has the responsibility to craft core competencies that encompass the totality of midwifery care. Midwives do not only care for women. Midwives care for people of all genders who are pregnant and give birth. Nothing about using inclusive language removes the right of women to refer to themselves in ways that feel appropriate to them.

The Open Letter recommends that midwives question the appropriateness of serving people who have undertaken gender affirming treatments, including common medications and surgical procedures.

“We wholeheartedly endorse inclusivity, which above all requires midwives’ provision of the particular care that transgendered people need. Toward that end, we see the need to gather more information on the ways in which body modifications, puberty blockers (Lupron), and long-term synthetic hormones may affect midwifery care in pregnancy and birth. Midwives are well aware of how body dysphoria can negatively impact pregnancy, birth, and breastfeeding. Before uncritically supporting gender transitioning, MANA should be calling for evidence precautionary to its long-term effects, especially in light of the younger and younger ages at which it is occurring. Before rushing into ‘inclusivity’ we need to focus on the clinical needs of transgendered people and an open reflection of whether and how these particular needs fit into the scope of practice for all midwives.”

No one has the right to determine the validity of a transgender person’s choices regarding their own transition-related care. We agree that more research needs to be done on the long-term effects of gender affirming medications and procedures. However, that research should be done in the spirit of ensuring that transgender and genderqueer people are getting the safest and most culturally relevant, respectful and life-affirming care possible, rather than in the spirit of attempting to prove that gender affirming care is clinically irrelevant or that having received gender-affirming treatments puts someone outside the scope of midwifery care.

Additionally, midwives routinely provide care to people who have taken a wide range of medications and undergone various surgical procedures. The intent of these treatments should not be used as justification to offer or deny care. The fact that gender affirming treatments are under-researched is evidence of institutionalized transphobia, but it is not unique. Many gender affirming medications and surgeries are commonly used for a wide range of other indications, both medical and cosmetic.

Our goal in writing this letter is to debunk some of the myths and misinformation in the "Open Letter to MANA" by Women-Centered Midwifery. It is also to remind people in the midwifery, birth work and reproductive justice community that trying to secure safe spaces for women does not mean having to de-legitimize the rights and very existence of transgender, genderqueer, and intersex people. We hope that you use this letter to:

Start conversations with other midwives and birth workers about what it means to support transgender, genderqueer and intersex people in your practice.

Reach out to the authors and signators of the open letter and tell them that they do not speak for you.

Learn more about providing sensitive and respectful reproductive health care for transgender, genderqueer and intersex people. The education around gender and sexuality should also include intersectionality with race and other social factors which impact people's reproductive health.

Post this letter on social media.

The signatures below indicate affirmation and respect for people of all genders; full agreement regarding the use of gender inclusive language in the MANA Core Competencies and in all documents regarding the profession of midwifery and provision of midwifery care; and the welcoming of transgender, genderqueer and intersex people into safe, culturally sensitive, shame-free reproductive health care. We do not refute the “life-giving power in female biology.” Rather, we support a larger vision that includes the provision of midwifery care to all pregnant and birthing people.